Been meaning to write about this since the results were first announced, but there’s been just too little time. It is great that the most prestigious prize in Medicine went to investigators who had worked on infectious (more specifically, parasitic) diseases.

Half of the Nobel prize was awarded to Dr Tu Youyou for her work on the discovery and development of artemisinin as an antimalarial compound, which has probably saved hundreds of thousands of lives as of today. This award for the discovery of artemisinin has long been anticipated – while it is not transformative (it is not the first antimalarial), there are very very few discoveries in medicine that have had the same global impact.

Left - 1951 photo of Tu Youyou with her teacher Lou Zhicen. Right - Artemisin annua plant (Credit: Wikipedia)
Left – 1951 photo of Tu Youyou with her teacher Lou Zhicen. Right – Artemisia annua plant (Credit: Wikipedia)

The story of artemisinin’s discovery (or perhaps I should say “re-discovery”) is a remarkable one that has now been written up in various periodicals, including BBC and the New York Times. I am somewhat embarrassed to admit I only came to learn about it in 2005, after 3 years(!) of infectious diseases training. It was at the Gorgas Course in Peru that the late Prof Alan Magill recounted the tale of the formation of the secret Project 523 in 1967 by Mao Zedong, answering a plea by the Vietcong General Vo Nguyen Giap in 1964 to devise a cure for malaria. We remember the napalm bombs, the Viet Cong tunnels, perhaps scenes and songs from Miss Saigon, but the less memorable though more prosaic reality of the Vietnam War was that more soldiers were killed or incapacitated by malaria on both sides than by the bullets and bombs.

Ge Hong's Handbook of Prescriptions for Emergencies, within which can be found the recipe for "intermittent fevers" using Artemisia Annua. Updated versions can be bought online today.
Ge Hong’s Handbook of Prescriptions for Emergencies, within which Tu Youyou found the recipe for “intermittent fevers” using Artemisia Annua. Updated versions can be bought online today.
Key figures in the discovery of artemisinin - General Vo from Vietnam and Chairman Mao.
Key figures in the discovery of artemisinin – General Vo from Vietnam and Chairman Mao.

A detailed history of Project 523 was compiled by Zhang Jianfang in 2006 and can be bought from Amazon for those who are interested in the story. In any case, Tu Youyou led the group that discovered artemisinin by 1977 (too late to be used for the Vietnam War), whereas the U.S. answer to the “malaria question” was mefloquine in 1979 (also too late to be used for the War!). One of the developers of mefloquine – Dr Keith Arnold – managed to make his way to China and compared the American vs. the Chinese drug in a clinical trial (published in the Lancet in 1984) which essentially showed the superiority of artemisinin.

Nonetheless, for reasons that are not entirely clear to me, WHO only endorsed artemisinin as an antimalarial in 2000 – in 2005, one still could not prescribe any of the artemisinin derivatives in Singapore (or rather, you could but your patient would not have been able to obtain the drug). Fast forward to today, we are now using artemisinin combination therapy as first-line treatment for falciparum malaria, severe vivax malaria, and even monkey (Plasmodium knowlesi) malaria. It is a particular bittersweet moment of recognition for the discovery of this drug however. Even now, the efficacy of artemisinin is being eroded in many parts of Southeast Asia and Africa by artemisinin-resistant Plasmodium falciparum, and it seems clear that the situation can only get worse in the next few years. A new and effective antimalarial drug is desperately needed soon.

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